Thanks to the persistent efforts of women like Brahmane and Vaksale, contraceptive acceptance for age group up to 19 years in Barwani, a village in Madhya Pradesh, has risen from 3 per cent to 13 per cent within a couple of years, writes Smita Deodhar.

Barwani: Kanchan Vaksale is well known in her little village of Ghatti in Madhya Pradesh (MP). As the ASHA (Accredited Social Health Activist), this 40-year-old has a packed schedule – she urges pregnant women in the community to go in for hospital deliveries and complete the full immunisation schedule for their newborn babies. She talks about sexual health with adolescents in the area, holding group meetings to discuss the physical and mental of changes during teenage, safe sex, and reproductive health. She even conducts ‘joda’ (couple) meetings and one-to-one counselling sessions on contraception for them.

Till date, Vaksale has reached out to 200 adolescents and convinced 12 of the 20 adolescent couples in her village to use contraception. This is a creditable feat in a community where early marriages and pregnancies are very common and contraceptive prevalence virtually non-existent.

Vaksale is an unwitting revolutionary in her conservative society, where it is unthinkable for a woman to discuss such topics publicly. She is one of the 900 ASHAs, who have been roped in by the Family Planning Association of India (FPAI) to implement its flagship project, ‘Addressing Adolescent Fertility’, in Barwani district of MP. “Working on this project was not easy. I did not know much about sexual and reproductive health earlier on. But once I received training under this initiative I have been updated on the subject, and have gained the confidence and courage to tackle any situation,” says the committed health worker.

The FPAI intervention covers 514 villages in seven blocks of Barwani district, and is financially and technically supported by the United Nations Population Fund (UNFPA). It has three objectives - to increase the mean age at first conception among married women between 15-19 years, promote spacing between children of married adolescents, and encourage care seeking behaviour for reproductive health among adolescents. Implicit in these objectives is an acceptance that adolescent sexual activity, sanctioned by society in the form of child marriage, is a reality in the country.

India has one of the highest child marriage rates in the world. According to the International Center for Research on Women (ICRW), 47 per cent of the women are married before they turn 18. The phenomenon is spread across communities and regions, and it is the adolescent bride who experiences the worst consequences of early marriage. Research indicates that for women, child marriage can lead to a higher risk for HIV infection, cervical cancer, sexual violence and maternal mortality. Additionally, in a traditional patriarchal set up, an adolescent bride is not able to negotiate the use of contraceptives, and has no say regarding the timing and number of children she bears - these decisions are made by family elders and the husband.

“Men and women in the age group of 14-19 enter into sexual relationships with little awareness of its responsibilities and consequences,” says Dr Kalpana Apte, Assistant Secretary General, Programme Implementation, FPAI. She has been working in this field for nearly two decades now, and has observed that adolescent sexuality is a neglected segment so far as national population policies are concerned. This is the lacuna that the Addressing Adolescent Fertility intervention seeks to address. While the FPAI has worked with young adolescent populations in various states on a smaller scale, it has scaled up its learnings through this district level initiative.

Barwani was a good place to start this pilot project, given its demographic - two-thirds of the population here is tribal. “Such societies have fairly liberal sexual practices, including pre-marital sex among adolescents. Early marriage and early pregnancies are common. About 30 per cent of the girls here get married before attaining legal age, and the percentage of births in the 15-19 age group is 22.8 per cent of the total births. The maternal mortality rate among the young mothers is also high,” informs Omendra Singh Chauhan, District Project Coordinator in Barwani.

It’s the ASHA cadre - already in place as a part of the National Rural Health Mission - that has been central to spreading the key messages. Mentored and trained by the FPAI, these gusty women with support from other stakeholders like school teachers, anganwadi workers and Panchayat members, have been working hard to make a difference to the lives of the young brides of Barwani. At the onset, villages were mapped and the number of adolescents - married and unmarried – was identified. This was followed up with the educational training, which the FPAI undertook while the government provided the supply back up.

For 24-year-old Lalita Brahmane, an ASHA, overcoming her own shyness about holding forth publicly on this subject was the first challenge. In spite of her initial reticence, in the two years that she has been involved with the project, she has regularly arranged and addressed four meetings a month, for different groups – adolescents, families, newly-wed couples with no children, and couples who have children.

Brahmane has achieved great breakthroughs – she has convinced 26 couples in her Chatli village to undergo permanent contraception, and has encouraged 12 young couples to adopt temporary contraceptive methods. “Trying to convince people - especially elders - and demolishing myths about contraception is a daily challenge. People do raise objections,” she remarks. Brahmane’s family has proved to be a great support for her. In fact, it’s her husband who accompanies her to the meetings, and even defends her activities before disgruntled elders.

Thanks to the persistent efforts of women like Brahmane and Vaksale, contraceptive acceptance for age group up to 19 years in Barwani has risen from 3 per cent to 13 per cent within a couple of years, prompting the FPAI and the UNFPA to extend the programme for another three years. “Eventually, the project will be handed over to the government, and will be implemented across the state,” says Chauhan.

Dr Apte sees the success at Barwani as a reason to be optimistic about the future. “Our experience here reveals that today’s young couples are not as strongly rooted within tradition as their elders, but they are caught between family culture and their own aspirations. This aspiration can be tapped. Engage with them, talk about health, a healthy next generation – and they are receptive.”

In tackling traditional mindset, the mass media can be a crucial tool. Dr Apte observes that the media is shaping the minds of youth even in the remotest corners of the country, and it has great potential for bringing about change. She says, “Preachy media won’t help. It is soaps and films, and even advertisements that are influencing young minds and creating an aspirational population. Customs that clash with their new ambitions are bound to get rejected.”

Dr Apte recommends that this nascent, yet perceptible momentum for change receive institutional support in the form regular and easily available supply of contraceptives, couple counselling, and confidentiality. “The ASHA worker must not declare to the family that the son is availing of condom supply from her. Existing channels of supply must be augmented. The cost of contraception is another major obstacle - for families where the monthly income is around Rs 1500 per month, a two-rupee condom does become a considerable expense. Consistent use will be possible only if the contraceptives are free,” she adds.

The Barwani experience holds out a hope that significant improvements in sexual and reproductive health practices in India may perhaps be just a generation away!